Assessment/ Diagnosis Background Goals and Interventions with evaluation

Cues objectives rationale

Subjective: Risk of According to Short term - Assess the Long term
Pain score on infection NANDA I goal: patient’s goal:
episiotomy related to (2018) an After 12 perineal area
wound is 5/10 episiotomy. episiotomy hours of for signs and GOAL MET
is a surgical nursing symptoms of
Vaginal cut made in intervention infection, The client will
discharge: the perinium client will be such as be able to
Lochia rubra during able to report redness, report a pain
childbirth to a pain level of swelling, level of 2 or
Amount: enlarge the 2 or less on a warmth, or less on a
Moderate vaginal scale of 0-10 drainage. scale of 0-10
opening and in the Assessing the in the
facilitate perineal care perineal area perineal care
Objective: delivery. for signs and
Vital signs: One of the long term symptoms of Short term
infection is
BP: 112/75 primary risks goal: goal:
particularly
mmHg associated After 24 important in
PR: 84 Bpm with hours of patients who GOAL MET
RR: 18 cpm episiotomy nursing are at
Temp: 37C is infection, interventions, increased risk After 24
which can the client will for infection hours of
result from demonstrate nursing
improper proper - Teach patient interventions,
hygiene perineal proper the client was
measures, hygiene hygiene able to
unsterilized techniques measures, demonstrate
instruments, during sitz including proper
and bath and keeping the perineal
underlying report relief perineal area hygiene
medical from clean and dry, techniques
conditions discomfort using mild during sitz
such as soap and bath and
diabetes or water, and report relief
weakened changing pads from
immune frequently. discomfort
system. The perineal
area is a
vulnerable site
for infection
due to its
location, and it
can become
infected for a
variety of
reasons,
including poor
hygiene,
 prolonged
exposure to
moisture, or
trauma

- Educate
patient on the
importance of
using sterile
techniques
when
cleaning and
dressing the
wound,
including
washing
hands before
and after
wound care
and using
sterile gloves
and dressings.
Educating
patients on
the importance
of using sterile
techniques
when cleaning
and dressing
wounds is
crucial in
preventing
infections and
promoting
wound healing

- Encourage
patient to
report any
signs or
symptoms of
infection
promptly to
prevent
complications.
Encouraging
patients to
report any
signs or
symptoms of
infection
promptly is
crucial in
preventing
complications
and promoting
recovery